ANNEX I: MONTHLY MATERNAL, NEONATAL and INFANT DEATH REPORTING FORM

MATERNAL DEATH REPORTING FORM

Case No. 1 Case No. 2 Case No. 3
Name Yna Magaspas
Barangay, Municipality Brgy. Katipunan, Rizal
Age 26
Gravida Parity G1P0
Number of Antenatal Check-ups (Indicate 1 Antenatal Check-up per
number of visit/s per trimester) Trimester
Birth attendant Doctor
(Doctor, Nurse, Midwife, TBA)
Date of Delivery May 1, 2015
Place of Delivery (Home, BHS, RHU, Hospital
Hospital, Others: Specify name of the
Facility also)
Date of Death May 1, 2015
Place of Death (Home, BHS, RHU, Hospital
Hospital, Others: Specify)
Time 11 am

Place
Woman died:
Cause of death
Three Delays Assessment
Cause of death (Medical)
Intervention (Medical and Non-medical)
PhilHealth membership
Hospital
Obstructed Labor
Delayed #2: Delayed in identifying and
receiving the appropriate facility.
Delayed #3: Delayed in receiving
appropriate and adequate care at the
facility
Obstructed Labor
Rushed to the hospital. C-Section.
NHTS 4Ps member
 ANNEX I: MONTHLY MATERNAL, NEONATAL and INFANT DEATH REPORTING FORM
(NHTS 4Ps, LGU sponsored or none)

NEONATAL/ INFANT DEATH REPORTING FORM

Case No. 1 Case No. 2 Case No.3

Name Gabriela Magaspas
Barangay Katipunan
Age (days/months) -
Sex Female
Date of Birth May 1, 2015
Immunizations Received None
Last immunization received
None
(Specify immunization and date.)
Exclusive Breastfeeding None
Date of death May 1, 2015
Place of Death
(Home, BHS, RHU, Hospital, Others: Hospital
Specify)
Delayed #2: Delayed in identifying
and reaching the appropriate
Three Delays facility
Delayed #3: Delayed in receiving
appropriate and adequate care at the
facility
Cause of death (Medical) Asphyxia
Intervention (Medical and Non-medical)
Caesarian Section
PhilHealth Dependent PhilHealth Dependent (LGU –
(NHTS 4Ps, LGU-sponsored or none) sponsored)
 ANNEX I: MONTHLY MATERNAL, NEONATAL and INFANT DEATH REPORTING FORM

Delayed #2: Delayed in identifying and reaching the appropriate facility – due to the distance from the woman’s home from the facility where
there is complete equipment and because the RHU in their barangay don’t have enough equipment to provide immediate care to the patient
they needed to transport the woman to the Hospital. The distance and the lack of emergency transportation to transport the woman it delays
the appropriate treatment to be given to the woman that cause the death of both the mother and the unborn child.

Delayed #3: Delayed in receiving appropriate and adequate care at the facility – Due to lack of healthcare personnel, lack of basic equipment, shortage of
supplies, and lack of budget from the LGU in the RHU the woman haven’t been given appropriate treatment and immediate care to both the mother and the
child. It is one cause of the death of both mother and the child.

MATERNAL DEATH REPORTING FORM

Case No. 1 Case No. 2 Case No. 3
Name Princess Ameerah
Barangay, Municipality Brgy. Sagrada, Baao
Age 25
Gravida Parity G3P2
Number of Antenatal Check-ups (Indicate 5 visit – 1st trimester
number of visit/s per trimester) 2 visit – 2nd trimester
3 – 3rd trimester
Birth attendant Doctor
(Doctor, Nurse, Midwife, TBA)
Date of Delivery November 10, 2020
Place of Delivery (Home, BHS, RHU, Hospital
Hospital, Others: Specify name of the
Facility also)
Date of Death November 10, 2020
Place of Death (Home, BHS, RHU, Hospital
Hospital, Others: Specify)
Time 3 pm
Woman died:
Place
Hospital
 ANNEX I: MONTHLY MATERNAL, NEONATAL and INFANT DEATH REPORTING FORM
Cause of death
Post-partum Hemorrhage
Three Delays Assessment Delayed #1: Delayed in deciding to
seek medical care
Delayed #2: Delay in receiving
appropriate and adequate care at the
facility
Cause of death (Medical) Hemorrhage
Intervention (Medical and Non-medical) Blood transfusion to the women
PhilHealth membership NHTS 4Ps member
(NHTS 4Ps, LGU sponsored or none)

Reasons:

Delayed #1: Delayed in deciding to seek medical care – due to their traditional beliefs in their community that all pregnant women should give
birth at their home, she decided to give birth at their home. And since they have the lack of money to pay for medical expenses and the cost of
transportation, they decided not to give birth at the RHU or in the hospital.

Delayed #2: Delay in receiving appropriate and adequate care at the facility – The woman arrived at the hospital where the last doctor whom
she last seen is working there, she is feeling unwell and dizzy during labor and after the labor she had postpartum hemorrhage. The hospital has
inadequate supply of blood and she needed immediate transfusion from her family members but since there are problem that arise the woman
died due to loss of blood during birth.